Case: Fuzzy Student Feb28

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Case: Fuzzy Student

Case Study: The Strange Case of Maggie Mae

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“I just feel exhausted all the time. I know it’s my first year in college, but I can’t seem to get with it.”

Case: Maggie Mae is an 18-year-old college freshman at a large state university. She comes into your office accompanied by her mother, who is concerned with Maggie’s complaints of constant fatigue, trouble focusing on her classwork, and “feeling fuzzy a lot of the time.” Mom also believes that Maggie has lost “too much” weight over the past semester.

Family History: Mother with multiple sclerosis, diagnosed four years ago. Father: alive and well. Two siblings: alive and well. Maternal grandfather with Parkinson’s disease; no family history of cancer or heart disease.

Past Medical History: Type 1 diabetes for 10 years. Her diabetes has typically been under adequate control, despite general dissatisfaction with dietary restrictions and insulin-related weight increases.

Social History: Until she moved into her dorm, she had always lived at home with overprotective parents. “Between all the socializing and a full class load, it’s no wonder I’m always exhausted!” Speaks enthusiastically of her suitemates, who are “motivating me to get in shape.”

Habits: Denies alcohol or illicit drugs. Eats three or four meals/day on school dining plan. Has not seen a dietitian in several years.

Current Medications: Basal long-acting insulin daily with 3 boluses of rapid acting insulin before breakfast, lunch, and dinner; antihistamines for seasonal allergies.

Physical Examination: Height: 65”; Weight: 123 lb (138 lb 14 weeks ago). Alert, oriented x 3, in no acute distress. Drinks from a bottle of water throughout the exam.

HEENT: within normal limits (WNL); Thyroid: Not enlarged, no bruit. Chest clear to PA. Cardiovascular: Heart sounds WNL; normal sinus rhythm. Abdomen: Liver, spleen, kidneys not enlarged, soft, active bowel sound, slight diffuse tenderness, no guarding, no rebound. Remainder of exam, WNL.

Laboratory: HbA1c: 9.3; FBS 277.

 

 

What is your diagnosis and how would you proceed?

Please click “Comment” to give us your diagnosis and next steps; read below for ours.

Together, Maggie’s symptoms present a clinical picture of hyperglycemia. However, two elements of her physical exam and labs are particularly troublesome: an elevated HbA1C (9.3) and a weight loss of 15 lbs over the past three months. Given that the HbA1c measures blood glucose levels over the past 8 to 12 weeks, Maggie’s lack of control is likely not a one-time oversight.

Young people on an intensive diabetes regimen are likely to incur a weight gain that is difficult to lose,[1] and Maggie is no exception. Given her newfound freedom from the constraints of home, the pressure among college students to be thin, and her roommates’ preoccupation with health and fitness, Maggie could be sabotaging her diabetes regimen and deliberately trying to lose weight. In fact, recent evidence suggests women with type 1 diabetes are 2.4 times more likely to develop eating disorders—or “disturbed eating”—than those without diabetes.[2]

Disturbed eating behaviors are very common among teenage girls with type 1 diabetes. Best estimates are that 45% to 80% of teen girls practice binge eating and that 12% to 40% deliberately reduce or eliminate insulin doses to promote weight loss.[3] Failure to take insulin causes blood sugar levels to rise, resulting in frequent urination and glycosuria. This glucose “purging” results in rapid weight loss and has the same effect as the purging techniques that bulimics employ to lose weight; therefore, some clinicians have proposed using the word diabulimia to describe the disorder.

Many clinicians are unaware of the condition or do not recognize it as a legitimate disorder. However, in an effort to bring more attention to it, several authors have suggested a working definition of diabulimia as “an insulin reduction at least twice a week OR a reduction of at least one-quarter of the prescribed insulin for the purpose of weight loss for more than three months.”[4]

You decide to question Maggie a bit more about her weight loss.

Apparently, Maggie had begun chatting with a young woman in a diabetes online support group who mentioned that she routinely manipulated her insulin to lose weight for special occasions. Although Maggie had always been dissatisfied with her insulin-related weight gain, her parents were able to provide support for her prescribed regimen. Now living on her own among peers who value thinness and fitness, Maggie found that decreasing her insulin doses on some days or completely eliminating it on others produced a pronounced weight loss that was admired by her peers.

Rather than berate Maggie for her choices, you might try to educate her as to the possible repercussions of her actions. Data suggest that teenagers with type 1 diabetes who misuse insulin to prevent weight gain have serious medical consequences in adulthood that include earlier onset of retinopathy, kidney failure, or foot ulcers requiring amputation.[5] Insulin restriction is associated with a threefold increase in mortality with the average age of death being 45 compared with 58 in those with appropriate insulin use.[5] 

If Maggie continues to practice disordered eating behaviors, the most effective treatment is a team approach comprising nutrition counseling, psychotherapy, and your medical intervention, with or without the help of an endocrinologist, depending on your comfort with managing type 1 diabetes. To encourage adherence, you might consider resetting her diabetes management goals so that they are less rigid and more realistic—at least initially. Sensitivity to her weight concerns is critical to success. Counseling is recommended to deal with the stress of a chronic illness and to further assess for other common psychological comorbidities, especially depression.

Published on February 28, 2012
Updated on March 6, 2012

References

  1. Goebel-Fabbri AE. Disturbed eating behaviors and eating disorders in type 1 diabetes: clinical significance and treatment recommendations. Curr Diab Rep. 2009;9(2):133-139.
  2. Jones JM, Lawson ML, Daneman D, et al. Eating disorders in adolescent females with and without type 1 diabetes: cross sectional study. BMJ. 2000;320(7249):1563-1566.
  3. Colton PA, Olmsted MP, Daneman D, et al. Five-year prevalence and persistence of disturbed eating behavior and eating disorders in girls with type 1 diabetes. Diabetes Care. 2007;30(11):2861-2862.
  4. Takii M, Uchigata Y, Nozaki T, et al. Classification of type 1 diabetic females with bulimia nervosa into subgroups according to purging behavior. Diabetes Care. 2002;25(9):1571-1575.
  5. Goebel-Fabbri AE, Kikkan J, Frank DL, et al. Insulin restriction and associated morbidity and mortality in women with type 1 diabetes. Diabetes Care. 2008;31(3):415-419.